CSAM
ADDICTION MEDICINE REVIEW COURSE
2004
Foundations of Addiction Medicine: Evidence & Art
October 6-9, 2004
12-STEP PROGRAMS
John Chappel, M.D.
and
Garrett O’Connor, M.D.
Chief Psychiatrist, The Betty Ford Center
Medical Director, Licensed Professionals
Treatment Program
Alcoholics Anonymous
“The Preamble”
Alcoholics Anonymous is a fellowship of
men and women who share their
experience, strength and hope with each
other that they may solve their common
problem and help others to recover from
alcoholism.
Alcoholics Anonymous (cont’d)
The only requirement for membership is a desire
to stop drinking. Thee are no dues or fees for
A.A. membership; we are self-supporting through
our own contributions. A.A. is not allied with any
sect, denomination, politics, organization or
institution; does not wish to engage in any
controversy, neither endorses nor opposes any
causes. Our primary purpose is to stay sober and
help other alcoholics to achieve sobriety.
“Alcoholics Anonymous has
been called the most significant
phenomenon in the history of
ideas in the 20th Century”
Quote from Lasker Award Citation to AA, 1951.
Why the 12-Step Programs?
• They really work!
• The spiritual approach of AA and NA has
helped millions of alcoholics and other drug
addicts.
• Most effective way of staying sober.
• Essential source for clinicians.
• Know how to refer and support.
• 12-Steps adapted to deal with over 200 human
problem behaviors .
THE GREAT CHALLENGE
FOR ADDICTION TREATMENT IN 2004
To integrate:
12-Step Spirituality,
Addiction Psychiatry,
Neurobiology
And
21st Century
Psychopharmacology.
TWO MODELS
(“BPSS”)
ABSTINENCE, SPIRITUALITY,
ACCOUNTABILITY, SERVICE;
HIGHER POWER AS A SPIRITUAL CONCEPT,
FAITH AND BIG BOOK AUTHORITY,
SPONSORSHIP, GROUP CONSCIENCE.,
12-STEP RECOVERY AS A WAY OF LIFE.
“PSYCHIATRIC”
DUAL DIAGNOSIS,
PERSONAL IDENTITY AS PSYCHIATRIC PATIENT,
MEDICAL AUTHORITY,
PRESCRIPTION AUTHORITY,
SCIENCE AND PSYCHOTHERAPY,
PSYCHOPHARMACOLOGY,
PSYCHIATRY (AND PSYCHIATRISTS) AS HIGHER POWER.
Estimated A.A. Membership and Group Info:
(Circa 2001)
Groups in US………………………………..….51,183
Members in US………………………….…..1,166,927
Groups in Canada………………………… …....5,257
Groups Overseas…………………………….…39,804
Members Overseas…………………………. 656,938
Internationalists……………………………………124
Groups in Correctional Facilities US/Canada… 2,466
Lone Members……………………………… ……347
Total
Members……………………………….….1,989,124
Groups………………………………………..98,710
Religion and Spirituality
“Religion is for people who are
afraid of going to hell; Spirituality
is for those who have already been
there.”
Ross V.
A.A. Member
12-STEP PROGRAMS
Best Known:
• Alcoholics Anonymous (AA)
• Al-Anon
• Narcotics Anonymous (NA)
• Cocaine Anonymous (CA)
• Gamblers Anonymous (GA)
• Overeaters Anonymous (OA)
• Debtors Anonymous (DA)
• Sex and Love Addicts Anonymous
(SLAA)
History of AA
• 1935: Two hopeless drunks, Bill W. and Dr. Bob
S., managed to stay sober by talking to each
other.
• Bill W. and Dr Bob decided to share their
experience, strength and hope with other
alcoholics, beginning in June 1935.
• 6/36
5 recovered
• 6/37
15 recovered
• 6/38
40 recovered
• 6/39
100 recovered (99 men, 1 woman)
• 1939 Big Book written by Bill W. with help of 3
groups. Separated from Oxford group, 1938
History of A.A.
(cont’d)
1941
Jack Alexander Article
in
Saturday Evening Post
History of AA (cont’d)
• Non-alcoholics involved from the
beginning
– Cooperation with professionals
– “AA wants to be friends with its friends.”
• Cooperation with the Professional
Community (CPC) Committee grew out
of desire to help suffering alcoholics.
History of AA (cont.)
• Research in 1980’s and 1990’s
– AA most effective way for alcoholics to
maintain long term sobriety. (Vaillant, 1983 &
1995)
• AA/NA compatible with treatment of all
medical and mental disorders.
• Should be considered essential in
treatment of addictive disorders.
How Does a 12-Step Mutual
Help Program of Recovery
Work?
See Chapter 5, “How It Works.” in
the Big Book of Alcoholics
Anonymous
Differentiate
“Program”
from
“Fellowship”
Program
Prescribed beliefs, values and behaviors of
12-Step Organizations. The 12-Steps.
Fellowship
Practice, activities and experience of a 12Step organization: e.g. service, helping
others, sharing, “working the Steps” etc.
Going To Meetings
• Acceptance of newcomers is warm and genuine.
• The Core activity is sharing of experience,
strength and hope:
– Honesty, Open-mindedness, and a
Willingness to change.
Many meetings to choose from
– Open, Closed, Beginners, Step Study, Big
Book Study, Speaker, Discussion etc.
12-Step Programs
Emphasize
ACTION!
Choosing A Home Group
• Can serve as both an extended family and
a recovery support system.
• A phone list is of great benefit
– shown significantly to reduce the risk of
relapse.
• Introduces service and responsibility.
Choosing A Sponsor
• Until a sponsor is acquired, ask for a
temporary contact who will introduce your
patient to the Fellowship and take them to
meetings.
• Main task of sponsor is to help work the steps
and develop a personal program of recovery.
• Having a sponsor significantly reduces the risk
of relapse (Sheeren, 1988)
• A sponsor will help the newcomer to work on
being Honest, Open-minded, and Willing
(H.O.W.)
Working the Steps
• Originally discovered through empirical
research to help hopeless, chronic
alcoholics maintain sobriety.
• Useful for compulsivities other than
alcohol or drug addiction.
Step One
We admitted we were powerless over alcohol that our lives had become unmanageable.
• Addresses denial.
• Promotes honesty and self examination,
resistance can be great.
• Accepts identity as an alcoholic or addict.
• Principle: Honesty.
Step Two
Came to believe that a power greater
than ourselves could restore us to sanity.
• The person recognizes that they need
help. “I alone can do it, but I can’t do it
alone.”
• Sanity is the recognition that continued
use of alcohol or other drugs will have
continued negative effects.
• Helps open the person to new internal
experience.
• Principle: Hope.
Step Three
Made a decision to turn our will and our lives
over to the care of God as we understood Him.
• Can be difficult for atheists and/or
agnostics; re-frame by thinking of an
accepting and loving life-force within.
• Practicing “letting go” weakens the
grip of obsessions, craving, worries,
resentments.
• Principle: Faith.
Step Four
Made a searching and fearless moral
inventory of ourselves.
• Done by many healthy individuals as a
fundamental part of psychotherapy.
• Arouses guilt, shame, grief, and other
powerful negative emotions. A sponsor is
necessary in working this step.
• Prepares person for honest sharing in
human relationships.
• Principle:
Courage.
Step Five
Admitted to God, to ourselves, and to another
human being the exact nature of our wrongs.
• Arouses shame, anxiety, reactions of anger,
disgust, and rejection.
• Usually given to one's sponsor, home group
member or clergy person. Shame reduction.
– great relief that reaction not rejecting or punitive.
• Helps develop honesty with oneself and
others.
• Principle:
Integrity.
Step Six
Were entirely ready to have God remove all
these defects of character.
• Characterologic and personality problems
continue.
• Simply getting ready to have a Higher
Power, something other than self, remove
selfishness, dishonesty, impulsiveness,
blaming, and other dysfunctional behaviors.
• Principle:
Willingness.
Step Seven
Humbly asked Him to remove our
shortcomings.
• Recognizes the fact that I am a fallible
human being who needs help.
• Antisocial, narcissistic, avoidant, and
borderline personality disorders slowly
subside and even disappear.
• Principle: Humility.
Step Eight
Made a list of all persons we had harmed and
became willing to make amends to them all.
• Painful, but a valuable preparation for
repairing damaged relationships.
• A sponsor is necessary in working this step.
• “If you have an unresolvable resentment about
someone, pray for the son of a bitch.”
• Essential part of capacity for empathy.
• Helps develop skill in maintain relationships.
• Principle: Love and Reparation
Step Nine
Made direct amends to such people wherever
possible, except when to do so would injure them
or others
•
•
•
•
Arouses anxiety which may be extreme
Sponsor support necessary.
Helps repair damaged relationships.
Restores the Balance of Justice
• Principle: Amends and Restitution
Step Ten
Continued to take personal inventory and
when we were wrong promptly admitted it.
• Self-observation, associational problem solving, and
honesty with oneself and others.
• Self-observation and admission of problems.
• Set the stage for re-developing both intimacy and
• generativity.
• Principle: Perseverance.
Step Eleven
Sought through prayer and meditation to improve our
conscious contact with God as we understood Him, praying
only for knowledge of His will for us and the power to carry
that out.
Emphasis is on developing the experience one is
capable of.
Knowledge & power are for taking responsibility
for one’s own life - solving one’s own problems.
Developing one’s own experience leads to
tolerance for others.
Continuing Surrender of the Will
Principle: Spiritual Awareness.
Step Twelve
Having had a spiritual awakening as a result of
these steps, we tried to carry this message to
alcoholics, and to practice these principles in all our
affairs.
• Refers to freedom from the bondage of
self-centeredness.
• “Spirituality is the ability to get our
minds off ourselves.”
• Action is carrying the message. Not a
sermon, or even good advice. It is a
personal sharing of the recovering
person’s experience, strength, and hope.
• Principle:
Service.
Correlation of 12-Steps with
Six Elements Important to the Success of
Psychotherapy*
1. Release of emotional tension in the context of
hope and expectation of receiving help.
2. Identification with the method.
3. Suggestion and persuasion.
4. Operant re-conditioning.
5. Repeated reality testing.
6. Cognitive learning about the basis for one’s
difficulties.
*Judd Marmor, M.D., American J. Psychiatry, April 1980
The Promises
1. We will know a new freedom and happiness.
2. We will not regret the past nor wish to shut the
door on it.
3. Comprehend the word serenity and know peace.
4. Realize how our experience can benefit others.
5. The feeling of uselessness and self-pity will
disappear.
6. We will lose interest in selfish things, and gain
interest in our fellows.
The Promises- (cont’d)
7. Self-seeking will slip away.
8. Our whole attitude and outlook on life
will change.
9. Fear of people and economic insecurity
will leave us.
10. We will intuitively know how to handle
situations which used to baffle us.
11. We will suddenly realize that God is
doing for us what we could not do for
ourselves.
THE TWELVE TRADITIONS
THE TWELVE TRADITIONS
ARE TO THE GROUP
WHAT THE TWELVE STEPS
ARE TO THE INDIVIDUAL.
THEY ARE A UNIQUE SET OF
ORGANIZATIONAL PRINCIPLES
DESIGNED SPECIFICALLY TO PREVENT
THE GROUP FROM DESTROYING ITSELF!!
The 12-Traditions
1. Our common welfare should come first; personal
recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate
authority – a loving God as He may express Himself in
our group conscience. Our leaders are but trusted
servants; they do not govern.
3. The only requirement for A.A. membership is a desire
to stop drinking.
4. Each group should be autonomous except in matters
affecting other groups or A.A. as a whole.
The 12-Traditions (cont’d)
5. Each group has but one primary purpose – to carry its
message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance, or lend
the A.A. name to any related facility or outside enterprise,
lest problems of money, property and prestige divert us
from our primary purpose.
7. Every A.A. group ought to be fully self-supporting,
declining outside contributions.
8. Alcoholics Anonymous should remain forever
nonprofessional, but our service centers may employ
special workers.
The 12-Traditions (cont’d)
9. A.A., as such, ought never be organized, but we may
create service boards or committees directly responsible to
those they serve.
10. Alcoholics Anonymous has no opinion on outside
issues; hence the A.A. name ought never be drawn into
public controversy.
11. Our public relations policy is based on attraction
rather than promotion; we need always maintain personal
anonymity at the level of press, radio and films.
12. Anonymity is the spiritual foundation of all our
traditions, ever reminding us to place principles before
personalities.
RESPECT THE TRADITIONS
• The 12 Traditions were developed to protect the
12-Step programs from external and internal
influences. They deal with:
–
–
–
–
–
–
1. GroupUnity
2. Group conscience
3. Membership
4. Group autonomy
5. Primary purpose
6. Non-affiliation
7. Self-support
8. Non-professional
9. Non-organized
10. No opinion on outside
11. Personal anonymity
12.Principles before
Personalities
Some Core 12-Step Concepts and
Applications
J. Scott Tonigan, et al. Spirituality and the 12-Step
Programs: A Guide for Clinicians
in
Integrating Spirituality Into Treatment
William R. Miller, Ph.D. (Ed.)
American Psychological Association, Washington, D.C.
PROGRESSION OF 12-STEPS
• Steps 1-3: Admission and acceptance of
powerlessness over alcohol,
unmanageability of life, surrender of
Will.
• Steps 4-10: Self-examination, amends
and restitution.
• Steps 11-12: Service.
A Power Greater Than
Ourselves
• Purposefully vague definition; individualized
concept; all persons are spiritual.
• Personal relationship with Higher Power;
influence on social interactions, employment
and financial issues, family and love
relationships, etc. Spiritual beliefs and values
for everyday living.
Mysticism
Steps 2, 3, 4, 5, 6, 7, 11, 12
• Belief in “Miracles”
• Co-incidences often seen as
manifestations of spiritual connectedness.
• Everything is linked in the universe of the
spirit
Amends and Restitution
Steps 8 and 9
Restoration of balance of
justice arising from offenses,
violations and betrayals of
others due to addiction.
Humility
Steps 1, 3, 7, 9, 10, 12
Antidote to shame, guilt,
narcissism, grandiosity,
omnipotence, immaturity,
Self-will Run Riot, etc.
Serenity
• The capacity to Remain
Serene in the face of
Catastrophe.
• The Serenity Prayer.
THE SERENITY PRAYER
God grant US the Serenity to accept
The things WE cannot change,
The courage to change the things WE can,
And the Wisdom to know the difference.
Service
Step 12
Having had a spiritual awakening as a
result of these steps we tried to carry
the message to other alcoholics, and to
practice these principles in all our
affairs
THE GREAT TRAGEDY AND THE AWFUL TRUTH
WE
ALCOHOLICS AND DRUG ADDICTS
HURT
THE ONES
WE LOVE
THE MOST
Gratitude
• For relief from pain and suffering;
• For shelter from isolation, alienation
and de-humanization.
• For the chance to heal.
• For restoration of hope and dignity
in self and others whom one has
blamed and harmed
Service Work
• Begins with meetings
–
–
–
–
Setting up
Making coffee
Greeting people
Cleaning up
• Continues with home group
– Secretary for meetings
– Chairing meetings
– 12-Step calls
• Committee work, eg. GSR, CPC, IG, H & I etc.
Service and Healing
• Altruistic - no expectation of recognition or reward.
• Exposes member to criticism.
– Dealing with negative emotion.
• Discovers that my problems help others (sharing and
12th step).
• May reflect spirituality.
• Develops purpose in life.
– “Whenever anyone anywhere reaches out I want the
hand of AA to be there, and for that I am
responsible.”
Slogans
• The man takes a drink; the drink takes a
drink; the drink takes the man.
• Let go, let God!
• Easy does it, but do it!
• One day at a time!
• Utilize, don’t analyze!
• Principles before personalities!
• Stinkin’ thinkin’.
• Principles before personalities.
Alano Clubs
•
•
•
•
Owned and run by 12-Step members
Not part of AA/NA/CA
Valuable sober environments
Usually many meetings
– Including group business
• Provide a daytime sober environment
• Coffee shop, pool tables, etc.
Clinicians working with
alcoholics and other addicts
should become familiar with
details of 12-Step program
principles, locations,
procedures and way of life.
REFERRAL TO AA
• Successful referral to a 12-Step program
requires support and contact.
• Systematic encouragement
– Clinician called AA member
– Patient/client talked briefly
– Arranged meeting and ride
– AA member called before meeting
• Result: 100% attendance ( N = 10)
• Standard referral: 0% attendance
(Sisson and Mallams: Am J Dr Alcoh Abuse, 8:371, 1981)
(The Doctor’s Voice: J Abnorm Psychol, 72:78, 1967)
Research in the 1990’s
• Two big multi-site studies
– Project MATCH (N = 1726)
• 10 sites
– Department of Veterans Affairs (N = 3018)
• 15 sites
(Projects MATCH: J Stud Alcoh, 58:7, 1997)
(Ouimette, et al: J Cons Clin Psych, 65:230, 1997)
Project MATCH
• 12 week, manual guided, individually
delivered treatments
– CBT - Cognitive Behavioral coping skills
– MET- Motivational Enhancement Therapy
– TSF- Twelve Step Facilitation
• Discriminable, high exposure.
• Similar therapist skill and therapeutic
alliance. (Carroll, et al: J Cons Clin Psychol, 66:290, 1998)
TSF
1. Reading Assignments.
2. Review journal - urges and slips and
Sober days.
3. Meeting attendance and
reactions.
4. Sponsor - getting started.
5. Use Telephone list
6. Step work.
(Proj MATCH: Vol 1: TSF Manual, 1995)
Dual Diagnosis Research
• Outcome
– 4 groups had comparable substance use outcomes
– DD groups had same improvement in each of 3
treatment programs
– 12-Step attendance associated with
• less psychological distress
• fewer psychiatric symptoms
– “These findings support the inclusion of 12-Step
participation as a component of continuing care
for DD patients.
(Ouimette, et al: Alcoh Clin Exp Res, 23:552, 1999)
How AA Changes Brain Function
and Behavior
Alcoholic/Addicted Behavior
• Impulsive
• Antisocial
• Immature
• Painful to self and others
• Common defense mechanisms
–
–
–
–
–
Denial
Minimization
Projection
Grandiosity
Acting out
Behavior in an Active 12-Step Program
of Recovery
•
•
•
•
•
Thoughtful
Honest
Open to learning and change - humility
Gratitude
Common defense mechanisms
– Altruism
– Humor
– Anticipation
– Suppression
– Sublimation
– Hope
Research Conclusions
• Twelve Step groups are normative
organizations that help members
– Experience, express, and manage feelings
– No negative feedback from others
– Help capacity for self-regulation
– Increase self efficacy and self care
– Improve relationship to others
– Find purpose and meaning
– Increase ability to listen to others
(Emrick: Text. Substance Abuse Treatment, p406, 1999)
NEGATIVE ATTITUDES OF PSYCHIATRY
TOWARDS AA
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUBSTITUTE DEPENDENCY
AA IS “ADJUNCTIVE”
A FOLK MOVEMENT
RELIGIOUS BIBLE THUMPING
A CULT
FOSTERS DEPENDENCY IN MEMBERS
NO FOLLOW-UP
NO CONTROLLED RESEARCH
EFFICACY NOT PROVED
DISORGANIZED
HOSTILE TO PSYCHIATRY
LACKS ACCOUNTABILITY
UNCOOPERATIVE
“THEY SMOKE AND DRINK COFFEE”
NON-INTELLECTUAL
FREE
•
•
•
•
•
•
•
•
•
•
•
•
NEGATIVE ATTITUDES IN AA
ABOUT PSYCHIATRISTS/PSYCHOTHERAPY
INSENSITIVE
DANGEROUS (ANTI-AA)
ARROGANT
DRUG-ORIENTED
IGNORANT ABOUT ADDICTION
ABUSIVE
NON-SPIRITUAL
MINIMIZE IMPACT OF ALCOHOL
MONEY-GRUBBING
COMPETITIVE
CONTEMPTUOUS
THREATENING
NEGATIVE 12-STEP ATTITUDES TOWARD
MEDICATIONS
•
•
•
•
•
•
•
•
•
•
A Crutch
Easier Softer Way
Impede Spiritual Recovery
Foster Dependency
Substitute for Higher Power
Violate AA Traditions
Bad Example for Newcomers
Ill-Trained Physicians
Stupid Physicians
Criminal Conduct by Docs
12-Step Programs
in Primary Care
1. Meeting schedules in each room
2. Pamphlets and Grapevine in waiting room
3. Patients or staff with good sobriety to take
newcomers to a meeting
4. Encourage staff to attend Alanon because
addicted patients are difficult
5. Don’t tolerate negative attitudes and remarks
to addicted patients.
(Marron: Primary Care, 20;107, 1993)
CENTRAL OFFICE OF AA
• The clinician’s doorway to the 12-Step
programs. Here you will find:
• INFORMATION – meeting schedules,
other 12-Step meetings and contacts
• LITERATURE – Most of AA’s and some
of the other 12-Step programs
• TEMPORARY CONTACTS for your
patients
References
12-Step Programs
1.
The Big Book of Alcoholics Anonymous (Alcoholics
Anonymous World Services, Inc. , Fourth Edition).
2.
Twelve Steps and Twelve Traditions (Alcoholics
Anonymous, World Services, Inc.)
3.
Clinical Guide to the Twelve Step Principles: by
Marvin D. Seppala, Hazelden/McGraw Hill
4.
Al-Anon Twelve Steps & Twelve Traditions: Al-Anon
Family Groups, Inc., New York 1993
THE GREAT CHALLENGE
FOR ADDICTION TREATMENT IN 2004
To integrate:
12-Step Spirituality,
Addiction Psychiatry,
Neurobiology
And
21st Century
Psychopharmacology.
TWO MODELS
(“BPSS”)
ABSTINENCE, SPIRITUALITY,
ACCOUNTABILITY, SERVICE;
HIGHER POWER AS A SPIRITUAL CONCEPT,
FAITH AND BIG BOOK AUTHORITY,
SPONSORSHIP, GROUP CONSCIENCE.,
12-STEP RECOVERY AS A WAY OF LIFE.
“PSYCHIATRIC”
DUAL DIAGNOSIS,
PERSONAL IDENTITY AS PSYCHIATRIC PATIENT,
MEDICAL AUTHORITY,
PRESCRIPTION AUTHORITY,
SCIENCE AND PSYCHOTHERAPY,
PSYCHOPHARMACOLOGY,
PSYCHIATRY (AND PSYCHIATRISTS) AS HIGHER POWER.
Conclusion
• Working a 12-Step program of recovery
is not easy
• Requires help from others, especially a
sponsor and a home group
• Cost of time and energy
When we refer to a 12-Step program two
benefits can be expected:
1. Sobriety, which sets the stage for
improved health, relationships, finances,
and learning.
Conclusion (cont.)
2. Mature Growth and Development
• Tasks of adult growth and development
• Intimacy, the ability to be genuine and
open with others
• Generativity, the ability to pass on what
one has learned to others
• Integrity, a sense of wholeness and
acceptance of one’s self
• Goes beyond the usual goals of medical
treatment, but one which any physician
can support.